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x s °` Town Hall, 53095 Main Road
�`' P.O. Box 1179
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Southold New York 11971
JUDITH T.TERRY FAX(516)765-1823
TOWN CLERK TELEPHONE(516)•765-1801
REGISTRAR OF VITAL STATISTICS OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1005-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner MACDOUGALL, THOMAS D.
Mailing Address 1 1275 MILL CREEK DRIVE
Mailing Address 2
City St Zip SOUTHOLD NY 11971-0000
Property Address 1 1275 MILL CREEK DRIVE
Property Address 2
City St Zip SOUTHOLD NY 11971-0000
Owner Telephone No. 516-765-3145
Tax Map No. section 135.00 block 3 lot 41 .000
Cross Street MEADOW LANE
Date Of Last Pump Out 7/00/87
Issue Date: 2/07/89 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
'.+
OFFICE OF THE TOWN CLERK SWFO
Town of Southold � . :� ._ re % Application No. Jo 0 5--
Judith T. Terry, Town Clerk .
Town Hall, 53095 Main Road `Y : Residential
p. 0. Box 1179 cn �..,, gat fir►
Non-Residential
Southold, New York 11971 O ® .• o/
- -s
Telephone : ' �( 1� •
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No.
Fee $ •
DATE
• OWNER NAME: •//ZS _ , l/,,ie ). 2I
OWNER MAILING ADDRESS: /c75 /If///
50v i it-/04h 9 7/
OWNER PROPERTY ADDRESS:
OWNER TELEPHONE NUMBER: 7e15--3/A-- ,
TAX MAP NO. : Section /3 s' Block ' 3 Lot 7/
CROSS STREET: ,A,odv/ L,gi6
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: 7- /11
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building 'and system; give north arrow and feet
of distance, approximately, to building and closest road.)
dismirivize; _ •
ignature of ° .plicant
RECEIVED BY: , • W� =
jo+n Clerk's Office
DATE: /9 /F,
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st __. . ..___
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